MO-28888_48094_CA_UST-61_20211108_24-Hour Release and UST Leak Reporting Form

UST-61 I 24-Hour Release and UST Leak Reporting Farm.
For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from
in NC
an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or
suspected release
Incident
(DWM USE ONLY) Suspected Contamination? (YIN) Facility ID Number
# Risk (H,I,L,U) Confirmed GW Contamination? YIN
Received On (YIN)_ Date Leak Discovered
Received e
Y Confirmed Soil Contamination ?(YIN) Comm/Non—Commercial-?-Reported by (circle one): Phone, Fax or Report Samples Taken?(YIN) ReglNon-regulated?
Region Free Product? (YIN) If Yes, State Greatest
Thickness
Incident Name:
INCIDENT DESCRIPTION
t . r a � �Y
r C ,�cc
Address:
County:
,414
Cityrrown: % Regional Otto circle one): Asheville, Mooresville, etteville,
`� b Zip Code: Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees) Longitude (decimal cegrees)n © Obtained by:
t
Briefly describe suspected or can armed release: (including but —not limited to: nature of release, date of release, amount
of reiease, amount of free roducf resent and recovery efforts, initial responses conducted, im acts to face fors ❑ GPS
—}-- / + �j� r t ❑ Topographic map
f �} O �' ❑ GIS Address matching
tu��� ❑ Other
❑ Unknown
Describe location_
HOW RELEASE WAS DISCOVERED (Release Code)
(Check one)
Release Detection Equipment or Methods ❑ VisuaUOdor ❑ Groundwater Contamination
During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination
Property Transfer ❑ Water Supply Well Contamination ❑ Other (specify)
SOURCE OF CONTAMINATION
Source of Release C
(Check one to indicate primary
ause of Release
(Check one to indicate primary
_LyPe of Release
(Check one)
Product Type Released
(Check to indicate prima product type
source)
cause)
releaone ed)
❑ Tank
PrIspill
❑ Petroleum
❑
Gasoline! Diesel/
❑ Diesel/Veg. Oil
❑ Piping
❑ Overfill
❑ Non -Petroleum
Kerosene
Blend
❑ Dispenser
❑ Corrosion
❑ Both
❑
❑
Heating Oil
❑ Vegetable Oil 100%
❑ Submersible Turbine Pump
❑Physical or Mechanical
Other Petroleum
Products
❑ E10 — E20
❑ Delivery Problem
Damage
Location
❑
Metals
❑ E21 — E84
❑ Other
❑ Install Problem
(Check one)
❑
Other Inorganics
❑ E85 — E99
❑ Unknown
❑ Other
❑F
Facility
❑
Other Organics
❑ Ethanol 100%
❑Unknown
❑ Residence
❑ E01—E09
Definitions presented on reverse Dofinitrons presented on reverse ❑ Other
Qwnershio
1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. EducationlRelig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02108)
1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes 2. No . Unknown
Number of Water Supply Wells Affected
Water Supply Wells Contaminated: (include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3,
UST SYSTEM OWNER
UST Owner/Company
ti
Point of Contact
Address
City
State Zip Code
Telephone Number
UST SYSTEM OPERATOR
UST OperatorlCampany
Address
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION
OF UST INCIDENT
Landowner
Address
,.
fz 1 +C
� c 3 � A
City
"ciiii
State
Zip Code
ghGne Number
Draw Sketch of
Area (showing two major road intersections) or Attach Map
44-
Lv L
Person Reporting In 'dent
Company
Telephone Number
Title
Address -; , �JL
Date �i 1
t U Page 2 of 2
Definitions of Sources
Tank: means the tank that stores the product and is part of the underground storage tank system
Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment (Vent, vapor recovery, or fill
lines are excluded.)
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank surnp), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut offat the dispenser)
Physical or Mechanical Damage: use for ail types ofphysieal or mechanical damage, except corrosion (e.g., punclure of tank or piping, loose fittings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined

Beverly, Trudy
From: Philip Thompson<[e-mail]>
Sent: Monday, November 8, 2021 3:58 PM
To: Beverly, Trudy
Subject: [External] Re: West Sugar Creek NRP
Attachments: Sugar Creek Corrections.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Attached is the corrected NORP, A revised IA and a UST 61. Aney Hensons Email is ahenson(abayrsley.com
On Mon, Nov 8, 2021 at 1:33 PM Philip Thompson<philipthompsongallgael(kgmail.com> wrote:
Could you call me.
On Mon, Nov 8, 2021, 1:31 PM Philip Thompson<philipthompsongallgaelkgmail.com> wrote:
I fixed the first page and am. Working on the UST 61, spectrum is still down.
On Mon, Nov 8, 2021, 1:12 PM Philip Thompson<philipthompsongallgael(agmmail.com> wrote:
Spectrum is down I can only access my cell phone. As soon as it is up I will do what I can
On Mon, Nov 8, 2021, 12:37 PM Beverly, Trudy <trudy.beverlygncdenr.gov> wrote:
Hey Phil,
There are a couple of issues with the first page of the NORP. I marked them with yellow electronic notes
on the attached page. Those can be fixed and we can swap out page 1.
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlykncdenr. gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: hi!ps:Hdcq.nc.2ov/about/divisions/waste-mana2ement/ust
Branch's Above Ground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httus://deq.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-mana eg mentig s=maps
File Review Procedures:
hgps:Hdeq.nc. gov/about/divisions/waste-management/ustlfile-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https:Hdeq.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
https://files.nc.sov/ncdealW aste%20Manauement/D WM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policy.pdf
hgps:Hfiles.nc. govincdeglWaste%20ManagementIDWMIUST/Con-ective%20ActionlUST%20file%20names%20for%20Laserfiche.docx